Friday, March 25, 2011

A tale of five patients..... a gluten story

In our practice, our focus is on chronic difficult to treat conditions using chiropractic, principals of functional neurology and functional medicine. Our philosophy is simple -“Fix the person, not their diagnosis”. Rather than label a patient with “x” disease, and give them a drug to suppress their symptoms, we want to be a really good detective. After performing a thorough history and exam, we run all the necessary tests which have not been done to find out what the underlying physiological mechanisms for each patient’s symptoms are. Why does this patient have these symptoms? It is not the same for everyone. A cookie cutter approach to chronic health problems simply doesn’t work.

While it is true that each patient is a unique individual ,there are some common underlying issues which must be addressed when dealing with chronic health challenges - anemia’s, blood sugar dysregulation, adrenal health, liver/GI dysfunction , errors in fatty acid metabolism, inflammation, autoimmunity and food sensitivities.

To illustrate the folly of treating a patient’s diagnosis or symptoms rather than addressing their physiology, I would like to share with you some actual cases from my office.

Patient #1 is a 9 year old boy diagnosed with ADHD. His parents were also concerned with his small stature (failure to thrive).

Patient # 2 is a 79 year old presenting with her chief complaint of peripheral neuropathy. She has also been diagnosed with polymyalgia, restless leg syndrome (RLS), Barret’s esophagus and Ulcerative Colitis. She has a son who suffers from MS.

Patient # 3 is a 51 year old woman who presents with chief complaint of hypothyroidism and related symptoms including fatigue, weight gain, thinning hair, constipation and cold hands and feet. She also has lupus. Her 15 year old son suffers from autism.

Patient # 4 is a 62 year old woman who presents with non alcoholic fatty liver disease (NAFLD). She has never had a drink of alcohol in her life.

Patient # 5 is 64 year old man who presents with peripheral neuropathy and a history of depression. Emg studies are all normal and he has been to several neurologist without any answers.

What Do All Five of These Patients Have in Common?

They all are gluten sensitive or Celiac patients. When they eat gluten ( a protein found in wheat and some other grains; spelt, kamut, rye and barley) they are triggering an inflammatory immune response . Although their symptoms and tissues being effected are different, the underlying trigger, gluten, is the same.

I am not saying that this was the only problem that these people had but it is a major factor in their health challenges and they are not going to get better without addressing it. There is no medication that can fix this. Diet and lifestyle changes are a must.

But wait a minute, only one of them had obvious GI symptoms. Unfortunately this confuses a lot of people, including physicians, this leads to a failure to identify and properly address the issue of gluten and wheat sensitivity. “That gluten sensitivity is regarded as principally a disease of the small bowel is a historical misconception” “Patients with enteropathy (disease of the intestinal tract) represent about only one third of patients with neurological manifestations and gluten sensitivity”(1)

Gluten is not a factor in every chronic health problem but it is one of the most common contributing factors.
The New England Journal of Medicine calls it one of the most common lifelong disorders in the United States. About 1% of the U.S. has Celiac Disease and 6% are gluten sensitive. Yet it is still very poorly understood and under diagnosed within the traditional medical community. The average Celiac patient has suffered with symptoms for 8 years and been to 5 doctors before being properly diagnosed. It is estimated that for every one person diagnosed there are at least eight others suffering silently.(2) Undiagnosed Celiac has been linked with an increased risk of mortality.

Every healthcare practitioner should understand the varying manifestations of gluten sensitivities and Celiac disease. Pediatricians, dentists, dermatologists, neurologists, psychiatrist/psychologists, chiropractors and others have the opportunity and responsibility to identify these individuals in their practices. Unfortunately, very few understand the clinical signs and symptoms including: Osteoporosis, osteopenia, central and peripheral nervous system disorders, anemia’s, weight loss or gain, tooth enamel defects, dementia, autism, Asperger’s, ADHD, schizophrenia, infertility, early menopause, vitamin k deficiency, depression, dermatitis, organ disorders and fatigue.

Another problem is that there is no one perfect test and there is disagreement over which test should be used. Historically, a definitive Celiac diagnosis required a positive endoscopy revealing villous atrophy ( intestinal tissue destruction). This is the end result of the process. Our goal as practitioners should be to catch things early and not wait until tissue destruction has become advanced and obvious. Yet, there are still doctors relying on biopsies to make this diagnosis. “The diagnosis of early celiac disease should be based on a combination of the clinical features, histology, serology and genetics. Conventional histology is not anymore the gold standard in the diagnosis. The diagnosis criteria need to be revised”(3) The Mayo clinic has suggested that the presence of the genes and any symptoms warrants the trial of a gluten free diet.

Recent advances in laboratory testing for gluten sensitivity and the related neuro-immunological repercussions should provide for more definitive answers and better treatment outcomes. These new testing procedures offer a more comprehensive, sensitive and accurate means to identify gluten sensitivity people. This will allow the knowledgeable practitioner to better serve their patients and community. These new procedures are some of the most cutting edge testing available and represent a new frontier in gluten sensitivity testing and treatment.

Two other problems a gluten reactive person can face are cross contamination and cross reactivity. Cross contamination comes from agricultural, storage and preparation techniques that expose a normally gluten free product or food to small amounts of gluten. Even in these small amounts, this can be enough to adversely affect someone. Oats are the best example of this. Technically gluten free, the majority of commercially grown oats are cross contaminated. When in doubt, it is best to avoid.

Cross reactivity is when a non-gluten containing food initiates a similar reaction in a gluten sensitive person. Some common offenders include: cow’s milk, cheese, chocolate, sesame, hemp, rye, barley, buckwheat, sorghum, millet, spelt, amaranth, quinoa, yeast, tapioca, oats, coffee, corn, rice and potato. Thankfully, laboratory testing for these reactive foods is also now available.

Simply removing gluten, wheat and other offending foods from the diet may not be enough. There is usually a lot of inflammation that must be addressed, an immune system that needs to be calmed down, and an abnormal gut flora (bacteria, parasites, yeast etc) that needs corrected. Fortunately, there are many natural substances - antioxidants, amino acids, vitamins and botanicals that can help us accomplish this.

Adopting a gluten free lifestyle, when necessary, is not an easy change to make but it is absolutely essential. Fortunately, as awareness grows there are becoming many more options available for gluten sensitive consumers. It is essential that you educate yourself on how to read labels. A good resource library is a must. Joining a support group or finding others who have made a similar lifestyle change can be very helpful. One complaint I hear often is “Gluten free food is so expensive”. It’s much cheaper than being sick. Remember just because it’s says gluten free doesn’t mean its good for you. I see many people filling up on gluten free junk food. A diet consisting of meats, nuts, seeds, vegetables , low glycemic index fruits and healthy fats is best. It is important to concentrate on all the things you can eat rather than dwell on the few things that you have to give up. With the help and guidance of a knowledgeable practitioner, you can take control of your health and change your life.

(1)J Neurol Neurosurg Psychiatry 2007;72. 560-563.
(2)Gastroenterology, 2001 636-651.
(3)Am J of Gastroenrol 2006 march 101(3)